The Sociodemographic Profile of Women Participating in Mammography Screening in Lower Silesia

NOWOTWORY Journal of Oncology 2017, volume 67, number 2, 89–95 DOI: 10.5603/NJO.2017.0014 © Polskie Towarzystwo Onkologiczne ISSN 0029–540X Original article www.nowotwory.edu.pl

The sociodemographic profile of women participating in mammography screening in Lower Silesia

Elżbieta Garwacka-Czachor, Adam Maciejczyk, Marek Bębenek

Introduction. Female breast cancer is the most common malignancy worldwide. An important element of cancer control involves population-based screening, which aims to reduce related mortality. Screening programs can only serve their purpose if they are long-term and available on a mass scale; accordingly, they are deemed effective as long as they cover at least 70% of the target population. Alarmingly, the coverage of breast cancer screening in Poland is markedly lower. The purpose of this study was to determine the impact of selected sociodemographic factors on the participation of women in mammography screening. Material and methods. The study included a population of Lower Silesian women aged 50 to 69, who participated in mammography screening, and analyzed a total of 32,626 questionnaires collected by means of a diagnostic survey between January 3, 2007 and December 30, 2011. Examined sociodemographic factors included the place of residence, age, educational level, and occupational status. Results. The largest group of screening participants comprised women aged 55 to 59 (30%), from Wrocław and the neighboring districts, with at least secondary education (74%), mostly old-age and disability pensioners (55%). Conclusions. Place of residence, age, education and occupation have a significant impact on the participation of Lower Silesian women in mammography screening. Age and disability pensioners aged 55–59 with at least secondary education are more likely to participate.

NOWOTWORY J Oncol 2017; 67, 2: 89–95

Key words: breast cancer, mammography screening, prevention

Introduction of the disease. This is helped by population-based screening Breast cancer is the most common malignancy world- programs, whose overarching goal is to reduce related mor- wide, representing a major health issue and a growing social tality rates. Detected early, breast cancer can be treated ef- and economic burden for many developed countries [1–3]. fectively with less radical methods, which directly translates A further systematic rise in its incidence in Europe, including into lower treatment costs. Early detection and treatment Poland, may be expected in the coming future. The trend is also reduce the risk of local relapse and distant metastasis, directly linked to the ageing of the European population and raising survival rates and improving the quality of life [9]. its increased exposure to lifestyle risk factors [4, 5]. Accordingly, the resolutions and recommendations of the In 2012–2013, 1,671,149 new cases were diagnosed European Parliament have repeatedly reiterated the impor- worldwide, including 494,077 in Europe, 17,142 in Poland, tance of screening as the most effective among the available and 1,417 in Lower Silesia. Corresponding standardized tools of secondary prevention [10–13]. incidence rates equaled, respectively: 43.1; 66.5; 51.8, and Adopted in 2005, the Act on Establishing the National 54.3 [6–8]. Cancer Control Program for 2006–2015 laid the groundwork A key role in the struggle against breast cancer is played for the implementation of the Population-Based Early Breast by secondary prevention, i.e. early detection and treatment Cancer Detection Program. The latter was elaborated in

Lower Silesian Oncology Center in Wrocław

89 accordance with the guidelines set down in the Council Table I. Women who participated in the Population-Based Early Breast Recommendation of 2 December 2003 on Cancer Screen- Cancer Detection Program at the Lower Silesian Oncology Center ing [11] and provided free mammography to women in the between 2007 and 2011 50–69 age group, which shows the highest incidence rate Year Number of women of breast cancer [14]. 2007 6,237 Screening programs can only serve their purpose if they 2008 5,558 are long-term and available on a mass scale; accordingly, 2009 6,326 they are deemed effective as long as they cover at least 2010 6,788 70% of the target population. This threshold has not yet 2011 7,717 been reached in Poland. According to statistical data for Total 32,626 the first half of 2013, the proportion of eligible women Source: Computer-based Prevention Monitoring System who participated in mammography screening was greater than 50% only in the West Pomeranian and the Lubusz Voivodeships. Everywhere else, it hovered between 37% and 49%; the relevant figure for Lower Silesia was 47% [15]. Statistical analysis Organizers and decision-makers alike are alarmed by the Study groups and variables were summarized by means low participation rate. of descriptive statistics, including the mean, standard de- The purpose of this study was to determine the impact viation, confidence intervals, and percentage distributions. of selected sociodemographic factors on the participation Measurable variables were tested for normality with the of Lower Silesian women in the mammography screening Shapiro-Wilk test and the Fisher test was used to assess the program at the Lower Silesian Oncology Center in Wrocław statistical significance of differences in the distribution of between 2007 and 2011. discrete variables. Changes that occurred in the successive years of the screening program were presented as trends Material and methods and regressions. The impact of age and education on the In 2011, approximately 3 million people lived in Lower willingness to participate the screening program was as- Silesia, more than half of them women (1,513,602). In ad- sessed by the homogeneity of variance test, followed by ministrative terms, Lower Silesia comprises 26 counties and the ANOVA single-factor analysis. The threshold of statistical 3 towns with county rights. A total of 395,852 women were significance was defined as p ≤ 0.05. All calculations were eligible for the Population-Based Early Breast Cancer Detec- performed in Statistica 10 and Microsoft Excel. tion Program run by the Lower Silesian Oncology Center [16]. In the end, 32,626 women aged 50 to 69 took part in the Results program between 3 January 2007 and 30 December 2011. The number of women who participated in the program Data from 32,626 questionnaires were collected and analyzed in successive years is shown in Table I. A slight but systematic in the Computer-Based Prevention Monitoring System [15]. increase in participation can be observed beginning in 2009. Alongside questionnaires, the analysis also included in- formation about the populace covered by mammography Sociodemographic factors screening, introduced into the system by the Lower Silesian Place of residence Voivodeship Coordinating Center for the Early Breat Cancer As shown in Table II, patients from Wrocław (77.9%) Detection Program, as well as statistical data obtained from and the neighboring counties (Wrocław, Oława, Trzebnica, the Central Statistical Office (GUS). Strzelin, Środa Śląska, and Wołów) accounted for 91.9% of Studies conducted in various countries have shown all women who took part in mammography screening at that health behaviors depend on a number of social and the Lower Silesian Oncology Center. demographic factors, such as age, education, marital status, family situation, social class, and material condi- Age tions [17–21]. This article focuses specifically on the age, The largest group (n = 9,889; 30%) comprised women education, occupational status, and place of residence of aged 55 to 59. Respondents between the ages of 50 and 54 screening participants under study. Women aged 50 to represented 29% of the screening group, while the propor- 69 were grouped into 5-year age brackets. Their level of tion of participants in the 65–69 age bracket was the lowest education was described on a scale ranging from incom- (n = 5,023; 16%). Figure 1 shows the distribution of the num- plete primary to a university degree. Occupational status ber of women who took part in the Population-Based Early was defined as the current occupation and the place of Breast Cancer Detection Program in 2009–2011 as a factor residence was listed as the nearest county. of age and testing year, along with relevant trend lines.

90 Table II. Number and percentage of eligible women who participated in the mammography screening by county

County, town Number of women, Lk Percentage of women, % Participating Eligible Participating Eligible City of Wrocław 25,201 92,051 77.9 23.3 Wrocław county 1,549 12,600 4.8 3.2 Oława county 802 9,671 2.5 2.4 Trzebnica county 701 9,568 2.2 2.4 Strzelin county 617 5,465 1.9 1.4 Środa Śląska county 425 5,815 1.3 1.5 Wołów county 419 6,011 1.3 1.5 Total: City of Wrocław + neighboring counties 29,714 141,181 91.8 35.7 Other counties, including: 2,648 254,671 8.2 64.3 Świdnica county 377 22,112 1.2 5.6 Dzierżoniów county 311 14,587 1.0 3.7 Ząbkowice country 308 9,121 1.0 2.3 Kłodzko county 226 23,632 0.7 6.0 Oleśnica county 197 12,995 0.6 3.3 Polkowice county 168 7,233 0.5 1.8 Jawor county 139 6,664 0.4 1.7 Głogów county 102 12,695 0.3 3.2 Lubin county 99 15,532 0.3 3.9 Milicz county 98 4,540 0.3 1.1 Bolesławiec county 94 11,621 0.3 2.9 Legnica county 65 6,739 0.2 1.7 City of Wałbrzych 63 10,000 0.2 2.5 Lubań county 58 7,688 0.2 1.9 City of Legnica 58 15,413 0.2 3.9 Zgorzelec county 56 12,654 0.2 3.2 Kamienna Góra county 45 6,056 0.1 1.5 Złotoryja county 44 5,749 0.1 1.5 Wałbrzych county 36 16,775 0.1 4.2 Góra county 34 4,180 0.1 1.1 Jelenia Góra county 25 8,958 0.1 2.3 Lwówek Śląski county 23 6,211 0.1 1.6 City of Jelenia Góra 22 13,516 0.1 3.4 Lower Silesian Voivodeship 32,362 395,852 100 100

Source: table created by the author based on data from the Central Statistical Office and the Computer-Based Prevention Monitoring system

During the first three years (2007–2009), an inverse rela- However, in 2010 and 2011, a proportionally higher number tionship could be observed between women’s age and their of older than younger women participated in the screening. willingness to participate in the program. In the fourth and fifth year (2010 and 2011), the majority of participants were Occupational status aged 56 to 62. The proportion of respondents over the age Old-age and disability pensioners represented the larg- of 65 was low throughout (Fig. 1). est group among screening participants (n = 17,929; 55%), Figure 2 shows the number of women who entered followed by white-collar workers (n = 7,865; 24.1%) and the screening program as a percentage of the total eligible blue-collar workers (n = 2,477; 7.6%). The smallest group population. In successive years (2007–2011), only slight comprised women who ran their own agricultural farms. changes were observed in these figures and their scope The percentage of pensioners continued to increase remained within one standard deviation from the mean. until the age of 60–64 and then diminished. For other

91 Figure 1. Distribution of Lower Silesian women participating in the Program as a function of age and testing year

occupational groups, participation systematically decreased primary school were 15% (n = 4,744) and 7% (n = 2,407), with age (Fig. 3). respectively. Respondents with primary and incomplete primary education were significantly older than those who Education completed at least vocational training (Fig. 4, Tab. III). Most respondents reported having completed second- No statistically significant correlation was shown to exist ary (n = 14,623; 45%) or higher education (n = 7,528; 23%). between the age and the educational level of women who Women who attended some college accounted for 6% participated in the screening program. Younger patients (in (n = 1,954) of all screening participants, and the correspond- the 50–54 and 55–59 age bracket), however, were slightly more ing figures for those who graduated from a vocational or likely to have completed secondary or higher education (Fig. 5).

Figure 2. Proportion of women who participated in the screening program relative to the total eligible population in successive years

92 Figure 3. Occupational structure of women who participated in the screening by 5-year age brackets

Figure 4. Relationship between the educational level and the mean age of screening participants

Discussion from large cities (in this case: Poznań), aged 55–59, with Breast cancer is the leading cause of premature death secondary or higher education [22]. Results of earlier studies among women, second in importance only to cardiovascular also suggest similar differences in the sociodemographic diseases. For this reason, it is particularly essential to identify profile of those who enter secondary prevention programs. the sociodemographic factors that affect the level of partici- It has been shown that they are more likely to be younger pation in mammography screening programs. and better educated [23–25]. In the current study, participation was significantly high- The largest group in the current study comprised pen- er among younger women (59% of all tests were performed sioners (55%), followed by white-collar workers (24.1%); in the 50–59 age bracket) who had completed secondary or women working on agricultural farms represented only higher education (74%) and lived in Wrocław (78%). Willing- 1.3%. The high proportion of pensioners among women ness to participate increased as a function of educational aged 50–69 who participated in the program may be ac- level, which reflects the greater awareness of health risks counted for in several ways. Firstly, because of the nature and lifestyle choices among better educated respondents. of Polish law, many could have acquired pension rights These data are consistent with the findings of another study, at a lower age. Secondly, as they are mostly out of work, conducted in 2011 in Greater Poland, which reported much pensioners have more free time to devote to prevention higher mammography participation levels among women programs. The study also showed that more than three

93 Table III. Statistical significance of the differences in the age of participants with different educational levels Education Mean age, p value 59.50 59.21 58.24 58.24 58.27 58.01 Incomplete primary 0.577 0.014 0.013 0.018 0.003 Primary 0.577 0.000 0.000 0.00 0.000 Vocational 0.014 0.000 0.998 0.862 0.019 Secondary 0.014 0.000 0.998 0.844 0.002 Incomplete higher 0.018 0.000 0.861 0.844 0.058 Higher 0.003 0.000 0.019 0.002 0.058

quarters (78%) of all participants lived in Wrocław, probably medical recommendations were not a sufficient motivat- because large urban centers tend to provide better access to ing factor. The only thing that could make them sign up for healthcare resources. This observation is consistent with the mammography was the discovery of a lump in the breast. findings of many previous studies conducted both in Poland Such an avoidance strategy means that many women and abroad [17–21]. undergo screening tests too late in the day, and if breast can- According to statistical data for 2002, the highest prema- cer is diagnosed, this leads to more aggressive treatment and ture mortality is observed among women with the lowest a significantly worse prognosis. In order to encourage better levels of education [26]. This was confirmed by the find- pro-health behaviors among Polish woman, it is essential to ings of the current study, which showed that women with raise their awareness of the role of prevention, impart indispen- vocational, primary, and incomplete primary education sable knowledge in accessible form, and ensure the motivation were significantly less likely to participate in mammogra- and support of local healthcare providers and communities. phy screening. Results of earlier surveys similarly confirm that these groups have a lower awareness of cancer, are Conclusions less likely to take care of their health, more often distrust 1. The place of residence, age, educational level, and treatment methods, and tend to doubt the effectiveness of occupational status have a significant impact on the preventive measures [27, 28]. In 2010, an opinion poll about willingness of Lower Silesian women to participate in the importance of breast cancer prevention was conducted mammography screening. among women in the villages of the Kuyavian-Pomeranian 2. The largest group of participants comprised women Voivodeship [29]. More than half had never taken a screen- from Wrocław and the neighboring counties, aged 55 ing test. Most admitted that their knowledge about the role to 59 (30%), most of whom were pensioners (55%) and of mammography, the presence of alarming symptoms, or had completed at least secondary education (74%).

Figure 5. Educational level of screening participants by 5-year age brackets

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